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Volume 16, Issue 3
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Spring 2004 |
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| published quarterly by: The New Hampshire Challenge, Inc. P.O. Box 579, Dover, NH 03821-0579 |
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| In This Issue |
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(42 U.S.C § 1396a(e)(3) or § 1902(e)(3) of the Social Security Act) |
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Any individual who-
(A) is 18 years of age or younger and qualifies as a disabled individual under section 1614(a) [42 USCS § 1382c(a)];
(B) with respect to whom there has been a determination by the State that--
(i) the individual requires a level of care provided in a hospital, nursing facility, or intermediate care facility for the mentally retarded,
See State Regulation He-W 508.03
(ii) it is appropriate to provide such care for the individual outside such an institution, and See State Regulation He-W 508.02(d) & (e)
(iii) the estimated amount which would be expended for medical assistance for the individual for such care outside an institution is not greater than the estimated amount which would otherwise be expended for medical assistance for the individual within an appropriate institution; and See State Regulation He-W 508.02(g)
(C) if the individual were in a medical institution, would be eligible for medical assistance under the State plan under this title [42 USCS § § 1396 et seq.],
shall be deemed, for purposes of this title [42 USCS § § 1396 et seq.] only, to be an individual with respect to whom a supplemental security income payment, or State supplemental payment, respectively, is being paid under title XVI [42 USCS § § 1381 et seq.].
Home Care for Children with Severe Disabilities (Katie Beckett)
(NH regulations - expired December 2002.)
He-W 508.01 Definitions.
(a) 'Active treatment program' means an aggressive, consistent implementation of specialized and generic training, treatment, health and related services directed toward:
(1) The acquisition of the behaviors necessary for the child to function with as much self determination and independence as possible; and
(1) The acquisition of the behaviors necessary for the child to function with as much self determination and independence as possible; and
(b) 'Family centered community-based home care' means an organized network of integrated and coordinated services delivered at the local level which promotes normal patterns of living and which recognizes the pivotal role of families with respect to the provision of services for their children.
(c) 'Cost effective' means the estimated medicaid cost of care outside an institution is no higher than the estimated medicaid cost of appropriate institutional care.
(d) 'Degree of care' means the level of intensity or extent of medical care, treatment or intervention required by the child as determined by the medical setting in which the child is being evaluated.
He-W 508.02 Recipient Eligibility.
(a) The purpose of family centered community-based home care shall be to support but not supplant the child's family as the primary caregiver.
(b) To be eligible for medical assistance for home care of certain children with severe disabilities, the child shall:
(1) Reside with at least one parent;
(2) Be able to receive services in the home as defined in 45 CFR 233.90(c)(1)(v)(B);
(3) Meet the program criteria as described 1902(e)(3) of the Social security Act;
(4) Meet the recipient criteria of He-W 641.04, except that, pursuant to the prohibition in 1614(f)(2)(B) of the Social Security Act on the deeming of parental income, the criteria of He-W 641.04(c)-(g) shall not apply;
(5) Meet the medical criteria as outlined in He-W 507.03;
(6) Require the same degree of care that is typically provided in a hospital, nursing facility or intermediate care facility for the mentally retarded as specified at He-W 508.03.
(c) In addition to the eligibility requirements described in (b) above, the services proposed for the child shall be:
(1) Medically appropriate, as determined by the joint medical review team in accordance with (d) and (e) below; and
(2) Cost effective as determined by OMS in accordance with (f) and (g) below.
(d) The joint medical review team, upon certification by the child's physician, shall determine if it is medically appropriate, in accordance with (e) below, for the child to receive family centered community-based home care as opposed to institutional care.
(e) The joint medical review team shall determine that family centered community-based home care is medically appropriate if the following conditions are met:
(1) The care can be provided in the home without jeopardizing the medical needs of the child;
(2) Medical and psychological support services are available in the community;
(3) The child's treating physician recommends home care and certifies the safety of home placement;
(4) The child's family or guardian have expressed a willingness and desire to assume responsibility as the primary caregiver(s) for the child in order to maintain the child at home; and
(5) The family and household members have been trained to support the child's needs in the home and have the ability to be primary caregivers.
(f) In order to maintain cost effectiveness, nursing care shall be allowed only up to 16 hours per day for at-home support, except as specified in (g) below.
(g) Cost effectiveness shall be determined to be maintained if nursing hours exceed 16 hours per day if the nursing care is provided:
(1) On a time-limited basis as documented in a medical plan of care; and
(2) For the purpose of the following:
a. To stabilize acute conditions; or
b. To transition a child from institution to home placement.
He-W 508.03 Degree of Care.
(a) In order to determine the most appropriate degree of care under which to evaluate the child, the joint medical review team shall review:
(1) The child's medical condition; and
(2) The child's community care needs.
(b) The joint medical review team shall determine that the degree of care provided by a hospital is appropriate for the child if the following criteria are met:
(1) The child requires hospitalization for an indefinite period of time; and
(2) Either of the following are met:
a. The child requires a complex care schedule and the use of sophisticated equipment designed to alert caregivers to potential life-threatening problems; or
b. The child has the constant potential for aspiration, respiratory obstruction or arrest, and/or other life threatening complications requiring the need for prompt, recurrent, skilled interventions to sustain life.
(c) The joint medical review team shall determine that the degree of care provided by a psychiatric hospital is appropriate for the child if the following criteria are met:
(1) The child meets the criteria in He-M 401.06 (a)(2), He-M 401.06(a)(3) and He-M 401.06(b);
(2) The child has specific symptoms and functional impairments that require professional and community interventions; and
(3) The child has problems of a chronic and severe nature requiring an intensive amount of professional supervision which are determined by an inability to function in the following major life areas:
a. Family relations;
b. Interpersonal and or social skills; and
c. Educational and or vocational skills.
(d) The joint medical review team shall determine that the degree of care provided by a nursing facility is appropriate for the child if any of the following criteria are met:
(1) The child is dependent on technologically sophisticated medical equipment such as, but not limited to ventilators, gastrostomy tubes, or central venous lines to sustain life;
(2) The child requires observations or judgments more than once per hour throughout a 24 hour period or continuously, to maintain health status;
(3) The child requires direct interventions from skilled nursing or skilled rehabilitative professionals to maintain health status;
(4) The child is dependent daily on less sophisticated medical equipment such as, but not limited to catheters, nebulizers, or oxygen to sustain life;
(5) The child requires observations and judgments less often than once per hour and not less often than once every 3 hours throughout the 24 hour period to maintain health status; or
(6) The child requires basic nursing and rehabilitative interventions under the direction and supervision of skilled nursing or skilled rehabilitative professionals.
(e) The joint medical review team shall determine that the degree of care provided by a intermediate care facility for the mentally retarded is appropriate for the child if the following criteria are met:
(1) The child has a developmental disability as defined in RSA 171-A:2, V;
(2) The child requires a continuous and pervasive active treatment program throughout the child's daily routine;
(3) There is a need for the continuity of treatment to and from all home and community-based settings; and
(4) Either of the following are met:
a. The child requires continuous medical monitoring for a chronic severe health problem, or
b. The child requires continuous supervision, monitoring, and redirection of behaviors associated with any condition, related to mental retardation, that results in impairment of general intellectual functioning or adaptive behavior. |
Related Stories:
Katie Beckett legislation delays changes
Katie Beckett Audit Released
Proposed changes to Katie Beckett regulations |
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